Original Research

Supporting Primary Care Patient-Centered Medical Homes with Community Care Teams: Findings from a Pilot Study

Journal of Clinical Outcomes Management. 2014 August;21(8)

Author(s):

Carol Foltz, PhD

Susan Lawrence, MS, CMAC

Nyann Biery, MS

Nancy Gratz, MPA, PCMH CCE

Hannah Paxton, MPH, RN

Deborah Swavely, DNP, RN

References

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From the Lehigh Valley Health Network, Allentown, PA.

Abstract

Objective: With the growing recognition that team-based care might help meet the country’s primary care needs, this study’s objective was to evaluate the preliminary effectiveness of multidisciplinary community care teams (CCTs) deployed to primary care practices transforming into patient-centered medical homes (PCMHs).
Methods: A nonrandomized longitudinal study design was used contrasting the CCT practices/patients with non-CCT comparison groups. Outcomes included utilization (ED/hospital use), quality indicators (QIs), practice joy, and patient satisfaction. Two CCTs (consisting of nurse care manager, behavioral health specialist, social worker, and pharmacist) were deployed to 6 primary care practices and provided services to 406 patients. Practice level analyses compared patients from the 6 CCT practices not receiving team services (29,881 patients) to 3 non-CCT practices (22,350 patients) that were also transforming toward PCMH. The comparison group for the patient level analyses (patients who received CCT services) was patients from the same CCT practice who did not receive CCT services.
Results: At the practice level, there were significant improvements in QIs for practices both with and without CCTs. However, reductions in the probability of an admission and readmission occurred only for high-risk patients in CCT practices. At the patient level, the probability of an unplanned admission was reduced for CCT and non-CCT patients, but the probability of a readmission was only reduced in CCT patients receiving hospital discharge reconciliation calls from CCT staff.
Conclusion: Preliminary results suggest possible added benefit of CCTs over PCMHs alone for reducing hospitalization.

As health care organizations move from a fee-for-service model to a value-based model in an accountable care environment, the transformation of primary care to patient-centered medical homes (PCMHs) is one of the fundamental strategies for achieving higher quality care at lower cost [1–3]. The core tenets of the PCMH are a commitment to high quality and safe care that is accessible, comprehensive, and coordinated across the health continuum, as well as patient-centered [4,5]. Newer to the PCMH model has been shifting the paradigm of care from individual encounters to using elements of population health management to proactively manage a panel of patients [1,3,6]. Given the array of patients seen in a primary care setting and the complexity of care required by many patients in a panel, particularly those with chronic conditions, a team approach to care capitalizes on multidisciplinary skills to collectively take responsibility for the ongoing care of the patients to improve health outcomes [7].

Multidisciplinary team-based care is considered a crucial strategy for meeting our society’s health care needs [8], especially in light of the expected shortage of primary care physicians coupled with the anticipated growth of the patient population due to the Affordable Care Act. Several different types of team-based care have been pursued. In 2003, for example, the State of Vermont pioneered health care reform through Vermont’s Blueprint for Health using principles of the PCMH that included team-based care [9]. The goal of the program was to deliver comprehensive and coordinated care to improve health outcomes for state residents. Vermont community health teams worked with primary care providers to manage short-term care for high-needs patients with an emphasis on better self-management, care coordination, chronic care management, and social and behavioral support services. An analysis of the first pilot program found significant decreases in hospital admissions and emergency department (ED) visits, and a per-person per-month reduction in costs [9].